Towards Quality Care for Patients. Fast Track to Quality The Six Most Critical Areas for Patient-Centered Care

Transcription

1 Towards Quality Care for Patients Fast Track to Quality The Six Most Critical Areas for Patient-Centered Care National Department of Health 2011

2 National Core Standards for Health Establishments in South Africa The Republic of South Africa, 2011 All rights reserved Published Tshwane, South Africa Further information regarding the National Core Standards and as welll as copies can be obtained from: Department of Health Private Bag X828 Tshwane 0001 Tel +27 (0) ACKNOWLEDGEMENTS The Department of Health would like to thank all contributors to the National Core Standards including, provincial colleagues, consultants, partners and donor agencies. ISBN

3 Contents 1. Introduction What patients are most concerned about Tools for change Requirements for compliance in the priority areas of the core standards Change in practice

4 1. Introduction There is a renewed emphasis in government on ensuring improved outcomes through a Negotiated Service Delivery Agreement - a performance management system with concrete roles for all stakeholders and regular obligatory monitoring. This means all efforts must be directed towards improving the health status of communities, strengthening the effectiveness of the health system and improving the quality of care provided. According to the Constitution of South Africa, all citizens have the right to healthcare that is caring, free from harm and as effective as possible. For more than 10 years, the principles of Batho Pele or people first have encapsulated the stated values of our public service. These principles are a simple and transparent mechanism which is intended to empower patients to hold the health services accountable for the quality of care they deliver. They are intended as a benchmark or standard for effective quality service delivery within the public sector as a whole. The Patient Rights Charter has made clear the responsibilities of our health facilities in delivering care that meets the principles of Batho Pele. The Charter specifies that the most critical rights of patients should be respected and upheld, including the rights of access to basic care and to respectful, informed and dignified attention in an acceptable and hygienic environment. Patients should be empowered to make informed decisions about their health and to complain if they have not received decent care. The National Core Standards have been developed over the past 2 years as a tool for management to guide their expected practice and assess whether they are in line with what is required (including the requirements of the Patients Rights Charter). They will also serve to benchmark all establishments against the same expected standards and will form the basis for external inspections to certify whether or not they are complaint. Over time, the process of monitoring compliance will result in significant improvements in the effectiveness and quality of the health system as a whole. 2. What patients are most concerned about Good quality care is about technical excellence as well as about the perceptions and experience of our patients and users, and of our staff. Based on the concerns and complaints raised by our patients, the results of surveys that have been carried out, and reports in the media, the Department of Health has identified some very specific areas where our patients feel that our services are furthest from what they expect and want and deserve. In accordance with the undertakings set out in the Negotiated Service Delivery Agreement for this term of government, the voice of our patients, as heard through regular surveys of patient satisfaction, as well as through a greater focus on managing complaints, will be a critical monitoring mechanism of the care we provide. 2.1 Caring staff and the feeling of being cared for: Health workers are far too often rude and uncaring to their patients. Patient complaints and patient satisfaction surveys both highlight this problem patients don t feel they have been treated well or in a caring manner at all times. Health workers in turn often tell us about their feelings of demotivation and a lack of recognition for their efforts. 2.2 Cleanliness of facilities: Contrary to our expectations about health facilities, our hospitals and clinics are often found to be dirty, untidy and unhygienic, showing that the staff do not care for or respect their patients or their own colleagues. Cleaning materials and equipment are often not adequate or not available at all when budgets are tight. Lack of maintenance reinforces the impression of neglect. This is one of the commonest problems raised in media reports, complaints and by visitors. 2.3 Waiting times to receive care: Patients are forced by circumstances to wait for hours to get their files, to see the nurse or doctor, and then to get their medicines. There are frequent reports of patients having to come back the next day to be seen; and even more shocking reports of patients who have died in the queue without being seen. There may be delays in referring patients needing urgent attention, or long waiting lists for specific treatment. 4 Fast Track to Quality: National Department of Health

5 2.4 Safety from accidental harm or medical errors: It is a common finding that even simple guidelines and protocols are not reliably implemented, which means that patients do not always receive the best possible care. The true frequency with which patients are actually harmed (though unintentionally) while in our care and due to our actions or omissions is not known however available reports of avoidable deaths or injuries, complaints we receive, and charges of professional negligence or malpractice, all point to a large problem. The physical security of patients and staff in our hospitals and facilities is also a major concern. 2.5 The risk of being infected in hospital: One very specific area of harm that is directly under our control is that of preventing the spread of infection in our hospitals and other facilities. In this respect many of the most basic rules and practices of hygiene are found not to be observed. Essential professional knowledge is not applied, procedures are not followed adequately and management does not prioritise this, with inadequate supplies of essential disinfectants and equipment and often problems with the proper disposal of medical waste. 2.6 Shortage of medicines: Shortages of medicines and supplies have become more and more common across the country. There are many reasons for this from supplier-related problems to budget-related lack of payment or failure to place orders with suppliers, from failure to distribute drugs to health facilities to problems with ordering things in time. Patients who are unable to receive the treatment they need on the day they come to collect it suffer not just the inconvenience and costs but possibly also the worsening of their condition. 3. Tools for change The National Core Standards for Health Establishments (full and abridged versions) provide the overall guide to quality care, organised into a number of domains. A set of measurement tools is available to help managers and staff themselves to understand whether or not they are compliant with these standards and have all the necessary systems in place to reduce the risk of poor quality or unsafe care. These tools are based on the evidence available on the ground that certain inputs, processes and outputs are in place (with those where failure to do so could potentially result in harm to patients or staff being further classified as vital ). Based on the serious concerns raised by patients and the public, the Department of Health has identified within these standards six priority quality areas for fast-track or immediate improvement (See figure 1, page 6). In choosing a few basic things and making sure they work well NOW, we will improve the way patients feel about the care they are receiving. They must be part of all our performance plans and all managers must focus on achieving these basic outputs every day. In addition to improving the way users experience the healthcare they receive, it is clear that in order to impact positively on people s health we must also improve the quality of care through the reliable implementation of best practices. Improving these six priority areas will also contribute to the outcomes or results we achieve: If best practice protocols are reliably implemented every time without errors or omissions, avoidable maternal, child and other deaths, and complications such as health-care acquired infections, will be reduced significantly. If the efficiency of referral and queuing systems is improved, the delays in receiving treatment that can sometimes mean the difference between life and death will be avoided. If essential medicines, supplies and equipment are always available and in working order, patients will not be deprived of quality care. Most importantly, through continuous encouragement and recognition of caring attitudes and professional excellence on the part of all staff, provision of best quality care will become the norm. Fast Track to Quality: National Department of Health 5

6 Figure 1: The National Core Standards and the 6 fast track priorities for improvement 1. Patient Rights 4. Public Health 2. Patient Safety, Clinical Governance & Care 3. Clinical Support Services 5. Leadership & Corporate Governance 6. Operational Management 7. Facilities & Infrastructure Patient Rights: 1. Values and attitudes 2. Waiting times 3. Cleanliness Patient Safety, Clinical Governance & Care: 4. Patient safety 5. Infection prevention and control Clinical Support Services: 6. Availability of medicines and supplies 4 Requirements for compliance in the priority areas of the core standards (extracted from the National Core Standards to reflect the specific measurement tool) 4.1 Improving values and attitudes our core values and the way health workers, care-givers, supervisors and managers interact with patients, visitors, family members and colleagues and respectfully address their concerns There should be evidence that: Patients are treated in a caring and respectful manner by staff who show appropriate values and attitudes and respect for patient privacy and choice Patient opinions provided through patient satisfaction surveys and via complaints and queries are used to improve service quality Patients can ask about the services and service times of the healthcare facility from a help desk and get other important information from clear signage Staff wear name badges to identify themselves and their position Patients receive the information they need before they formally agree to any treatment or participate in a study. Patients receive information when they are discharged that allows them to continue their care at home or to receive ongoing care at a clinic or doctor Patients who wish to complain about poor service are helped to do so and their concerns are properly responded to by management, who use complaints to improve service delivery at that facility Leaders at all levels provide positive role models to staff and encourage a culture of caring and of positive attitudes that support service delivery 6 Fast Track to Quality: National Department of Health

7 4.2 Cleanliness of our hospitals and clinics the degree to which a health facility its buildings, grounds, amenities, equipment and staff - are spotlessly clean and tidy There should be evidence that: Patients are satisfied with the cleanliness and hygiene of the facility and their accommodation, linen and amenities The buildings, wards, toilets, public areas and grounds are kept clean and hygienic to maximise safety and comfort Cleaning materials and equipment are available and staff and managers ensure their proper use in maintaining the cleanliness of the facility General waste (e.g. office, kitchen, garden or household waste) is managed to ensure general cleanliness and visual aesthetics Healthcare clinical waste (e.g. human tissue, soiled dressings, used syringes) is handled and disposed of safely to reduce health risks to patients and protect the environment and the public from unnecessary exposure 4.3 Reducing waiting times and queues reducing the total time patients must wait for administration, assessment, diagnosis, pharmacy, surgery and other care; as well as reducing the delays in referral time and transfer for further care when needed There should be evidence that: Waiting times and queues in busy areas (including outpatients, pharmacy and casualty) are monitored and managed to improve patient satisfaction and care Patients are helped on the day they arrive seeking care Queues are managed to ensure that serious and high risk patients are attended to as first priority Waiting lists and delays in accessing care are kept as short as possible 4.4 Keeping patients safe and providing reliable care - actions to reduce unintended harm to patients or staff ( adverse events ) resulting from the care given, including from the operations and failures of the health system and its workers, through ignorance, inadequate inputs, systems failure or at time from negligence There should be evidence that: Patients receive care and treatment that meets their basic needs and contributes to their recovery by ensuring that basic care and protocols are followed Proper care is provided according to guidelines especially for women and children and in cases of priority diseases as set out in the United Nations Millennium Development Goals (for HIV and tuberculosis) Patients with special needs or at special risk, such as pregnant women, young children, the mentally ill or the elderly, receive special attention Specific safety protocols are in place for patients undergoing high risk procedures such as surgery, blood transfusions or resuscitation Proactive clinical risk identification occurs in each ward or area in order to prevent adverse events from occurring All adverse events are identified and promptly responded to, in order to protect the patient from further harm and suffering Fast Track to Quality: National Department of Health 7

8 Adverse events are routinely analysed and managed in order to prevent recurrence to future patients, to learn from our mistakes and to respond to any Medico-legal cases Mortality and Morbidity meetings are held at least monthly to evaluate patient deaths and put in place measures to avoid further preventable deaths A quality improvement programme is implemented for all identified patient safety risks or poor clinical outcomes and is regularly monitored Sorting systems in waiting areas identify patients requiring urgent attention and allow them to be treated as a priority, including the stabilisation of emergency patients prior to any transfer Medicines are prescribed according to treatment guidelines and pharmacists educate their patients to understand how and when to take their medication correctly Reactions to drugs or severe side effects are reported and treated Laboratory and X-ray services are available and provide accurate and good quality results or reports in an acceptable time Medical equipment and devices for safe and effective patient care are available functional and properly maintained and staff are trained in their correct use The hospital board or clinic committee makes sure that quality care is provided and that any shortcomings are addressed by management Senior leaders and managers proactively drive efforts to foster a no-blame culture and address the underlying causes of medical errors to improve patient safety Buildings are adequately compliant with legislation and safety standards to ensure a safe environment for staff and patients and are maintained and regularly inspected to identify safety risks Adequate physical security and access control of the buildings and grounds is provided to protect patients and staff from security threats Emergency plans in the facility are aimed at protecting public safety in the event of significant disease outbreaks or other health emergencies 4.5 Preventing infections from being passed on in our hospitals and clinics Interventions to specifically focus on health-care-acquired infections as one kind of unintended harm to patients in facilities There should be evidence that: An Infection Prevention and Control Programme to reduce healthcare associated infections is implemented at the facility including a strategy and policy, and a reporting and surveillance system A trained healthcare professional oversees and drives infection prevention and control in the facility with a formal Committee structure for support and guidance Specific precautions are taken to reduce or prevent the spread of respiratory infections including Tuberculosis Standard precautions including hand washing and proper disposal of sharps are applied to prevent health care associated infections Strict infection control practices are observed in all food preparation areas and milk kitchens to prevent infection risks Decontamination and sterilisation services are available and effective Staff are protected from exposure to risks (including infection) through occupational health and safety systems General waste management in the establishment and surrounding environment complies with legal requirements, national standards and with good practice Healthcare waste is handled, stored and disposed of safely to reduce potential health risks 8 Fast Track to Quality: National Department of Health

9 4.6 Making sure medicines, supplies and equipment are available - all the steps in the supply chain which make sure that patients get their prescribed medicine on the same day There should be evidence that: Prescribed medicines and medical supplies are available as needed Procurement, payment and delivery processes are reliable and on time Stock levels of medicines and medical supplies are managed to prevent stock shortages and stock loss and they are properly stored and controlled Contingency plans are in place to maintain the cold chain for medicines and vaccines 5 Change in practice In many excellent public facilities, successful projects and initiatives driven by their management teams or staff or by groups of professionals and academics are already showing results, in some cases with support from partners or service providers. Such efforts tend to be found in hospitals and clinics that are already striving to improve and to provide excellent care. They need to be helped to improve further through continuous self-assessment, removing the obstacles and barriers to improvement and scale-up, making sure that information systems can continuously drive improvement and show results, and that successes are recognised and shared. Of concern however are a number of weaker facilities (or certain departments within some large facilities) where care is poor, staff are demotivated and management appears to be ineffective. Such facilities or departments need a different approach of supported self-assessment and concerted efforts to correct the weakness found. This must be linked to providing strong support, development and training where needed, and to performance management processes. This will be the only way to avoid an external assessment that results in the certification of non-compliance. Better coordination and integration of efforts at national and provincial levels are a key success factor in enabling this. Others are the delegation of needed authority, effective prevention of fraud and wastage, fast and efficient administrative and bureaucratic processes, and most importantly, competent and supportive management. In achieving better management, there are a number of concrete methods (in addition to improved compliance with standards) which will ensure that change actually happens: regular and supportive supervision and mentoring of frontline staff; ongoing surveillance of avoidable deaths and complications in order to correct weaknesses; greater attention to the opinions of our patients as reflected in patient satisfaction surveys and complaints; the analysis and use of information by managers to improve their results; and improved performance management that is linked to the health system goals. The task is therefore to rapidly improve the situation in specific areas, especially in the identified priority areas, through using effective approaches of process change and scaling up those interventions that make a measurable difference. Fast Track to Quality: National Department of Health 9

10 Notes 10 Fast Track to Quality: National Department of Health

11

12